Kids Do the Darndest Things! Kids Do the Darndest Things! Eleanor Erwin M. D. f for James R. Williams, AAS, NRP, I/C
Kids Do the Darndest Things!Kids Do the Darndest Things!Eleanor Erwin M. D.
fforJames R. Williams, AAS, NRP, I/C
Obj tiObjectives
• Epidemiology of pediatric ingestionsp gy p g
• Physiological Differences
• General poisoning treatment strategies
• Salicylates
• Acetaminiphen
• Common Drugs- Lethal prescriptions
E id i lEpidemiology
• 1.5 million calls a year for pediatric ingestion
79% are for kids less than 6• 79% are for kids less than 6
• 56% are from products around the house56% are from products around the house
Ph i l i l DiffPhysiological Differences
• Blood brain barrier more permeable until 4 months
• Higher metabolic demands
• Decreased glycogen stores
• Inability to avoid hazards - they don’t read the signs!
G l M tGeneral Management
• What is it?
• How much is it?
When did they take it?• When did they take it?
• What else did they take with it?What else did they take with it?
• Why did they take it?
G l M tGeneral Management
• Airway
• Breathing
Circulation• Circulation
• DisabilityDisability
• Basic observations
UUse your senses
• Look
• Track marks, pupil size, skin
• Hear
• Type of breathing
• Feel
• Temperature
• Smell
• Ketones
• Alcohol
• Taste? (OK, not this one)
M tManagement
Decrease drug absorption• Decrease drug absorption
M tManagement
Increase drug elimination• Increase drug elimination
M tManagement
• Antagonize the effects of the poisong p
• Naloxone
• N-acetylcysteine
• Digibind
• Flumanzenil
• Fomepizol
S li l t 'Salicylate's
Wh i it f dWhere is it found
H d it d h t it d ?How does it do what it does?
• Inhibits prostaglandin synthesisInhibits prostaglandin synthesis.
• Directly inhibits neutrophils to decrease the i fl tinflammatory response.
P th h i lPathophysiology
• Stimulates the brainstem causing hyperventilationg yp
• Causes renal impairment which leads to the faccumulation of acids
Interferes with the Krebs cycle• Interferes with the Krebs cycle
• Causes body to generate heatCauses body to generate heat
• Causes fatty acid metabolism which produces ketone bodies.
H h i h?How much is enough?
• Ingestion of 150 mg/kg causes intoxication
• Level of 50 - 80 mg/dL causes moderate symptoms
• Severe symptoms over 80 mg/dL
• Clinical presentation is more important that numbers!
M if t tiManifestations
• Early - non specific signs (i.e. nausea, vomiting)y p g ( , g)
• Tinnitus, sometimes with hearing loss
• Hyperventilation
CNS signs• CNS signs
• Vertigo
• Hallucinations
• Stupor
t t ttreatment
• ABC’s
• History and Exam
Activated charcoal should be given• Activated charcoal should be given
• 25 to 100 grams25 to 100 grams
• Sodium Bicarbonate-Call Medical contol
H di l iHemodialysis
• This is for the most severe cases
• Renal failure
• CHF
Acute lung injury• Acute lung injury
• Persistent CNS disturbance
• Severe acid base imbalance despite treatment
• Hepatic compromise
A t i hAcetaminophen
Wh i it f d?Where is it found?
H d it d h t it d ?How does it do what it does?
A l i i d d b th i hibiti f COX 2 d• Analgesia is produced by the inhibition of COX-2 and prostaglandin
• Antipyresis at slightly higher blood levels through CNS depressiondepression.
H h i h?How much is enough?
• Adults – 140 mg/kg or greater or 7.5 grams in 24 hours
• Children <10 - >200 mg/kg
Wh t h i d ?What happens in overdose?
• Liver enzymes become saturated
• Glutathione is depleted
• NAPQI accumulates
• Hepatic necrosis ensues
Gl t thiGlutathione
• This is an antioxidant who’s purpose in life is to keep cells running smoothly.g y
• It is found in every cell
NAPQINAPQI
• N - acetyl-p-benzoquinoneimine
• This is a metabolite of acetaminophen
Acetaminophen PoisoningAcetaminophen Poisoning Phases
• Phase I
• 30 minutes to 4 hours
• Anorexia
Nausea vomiting• Nausea, vomiting
• Pallor
• Diaphoresis
• Malaise
Acetaminophen PoisoningAcetaminophen Poisoning Phases
• Phase II
• 24 to 48 hours
• Symptoms lessen and it may seem the patient is getting better.
Right upper quadrant pain• Right upper quadrant pain
• Liver enzymes become abnormal
• Clotting times prolonged
• Renal function deteriorates
Acetaminophen PoisoningAcetaminophen Poisoning Phases
• Phase III
• 3 to 5 days
• Symptoms of hepatic necrosis
• Hepatic encephalopathy
• Nausea, vomiting
• Death due to hepatic failure
Acetaminophen PoisoningAcetaminophen Poisoning Phases
• Phase IV
• Resolution
• Death
T t tTreatment
• ABC’s
• History and Exam
• Activated Charcoal
• Hemodialysis?
N t l t iN-acetylcysteine
• Glutathione substituteGlutathione substitute
• Administered orally or IVy
• They need this as soon as possible as it prevents li dliver damage
C l i Ch l Bl kCalcium Channel Blockers
• Used to treat hypertension, migraines, Raynauds.yp , g , y
• Include:
• Norvasc
• Cardizem
• Procardia
• Verapamil
C l i Ch l Bl kCalcium Channel Blockers
• Can cause:
• Hypotension
• Bradycardia
• Arrhythmia's
T t tTreatment
• ABC’s
• History and Exam
Fl id• Fluids
• Will need:
• Calcium
• Glucagon• Glucagon
• Insulin
• Atropine
TCATCATricyclic AntidepressantsTricyclic Antidepressants
Wh t D it ?What Does it cause?
• Anticholinergic Effects
• Dry mouth
D• Dry eyes
• Dilated pupils
• Urinary retention
• Blurred vision• Blurred vision
• Dizziness
• Palpitations
Wh t d it ?What does it cause?
• CNS effects
• Confusion
• Delirium
• Coma
• Convulsions
• Respiratory depression
T t tTreatment
• Initial management is supportiveg pp
• Control seizures
• Activated charcoal if they have received more than 4 mg/kg in one hour
• Treat hypoxia with oxygen
• Correct acidosis with sodium bicarbonate
• Correct arrhythmia's
Iron
Wh i it f dWhere is it found
H h i b d thi ?How much is a bad thing?
• Toxicity occurs at as low as 10 mg/kg
Prenatal vitamins typically contain 65 mg• Prenatal vitamins typically contain 65 mg
• Children’s vitamins contain 10-18 mgChildren s vitamins contain 10 18 mg
H b d d it t?How bad does it get?
• Phase I
• Nausea, vomiting, abdominal pain, diarrhea
Phase II• Phase II
• 6 - 24 hours6 24 hours
• GI symptoms will resolve
H b d d it t?How bad does it get?
• Phase III
• Shock stage occurs
• Poor cardiac output
• Hypovolemia
• Lethargy
• Seizures
H b d d it t?How bad does it get?
• Phase IV
• Liver failure continues
• Phase VPhase V
• Gastric outlet obstruction occurs
T t tTreatment
• ABC’s
• History and Exam
• Very aggressive fluid resuscitation
• Patients will need whole bowel irrigation
• Patient may need blood products
• Deferoxamine can combat this
SSummary
• Remember the basic strategy of poisoning treatmentRemember the basic strategy of poisoning treatment
• Pre-hospital providers mainly provide supportive carep p y p pp
• Pre-hospital providers are the first line in assessment d di iand diagnosis